Final Review

A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis? a. Painless red vaginal bleeding b. Increasing abdominal pain with a nonrelaxed uterus c. Abdominal pain with scant red vaginal bleeding d. Intermittent abdominal pain following passage of bloody mucus

a. Painless red vaginal bleeding

A nurse is providing teaching to a client who is pregnant and has phenylketonuria (PKU). Which of the following foods should the nurse instruct the client to eliminate from her diet? a. Peanut butter b. Potatoes c. Apple juice d. Broccoli

a. Peanut butter

A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse should recognize this finding as an indication of which of the following conditions? a. Abruptio placentae b. Placenta previa c. Precipitous labor d. Threatened abortion

b. Placenta previa

A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications? a. Anaphylactoid syndrome of pregnancy b. Disseminated intravascular coagulation c. Preeclampsia d. Puerperal infection

b. Disseminated intravascular coagulation

A nurse is caring for a newborn who has myelomeningocele. Which of the following nursing goals has the priority in the care of this infant? a. Maintain the integrity of the sac. b. Promote maternal-infant bonding. c. Educate the parents about the defect. d. Provide age-appropriate stimulation.

a. Maintain the integrity of the sac.

A nurse is assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority? a. Saturated perineal pad in 30 min b. Deep tendon reflexes 4+ c. Fundus at level of umbilicus d. Approximated edges of episiotomy

b. Deep tendon reflexes 4+

A nurse is admitting a client who experienced a vaginal birth 2 hr ago. The client is receiving an IV of lactated Ringer's with 25 units of oxytocin infusing and has large rubra lochia. Vital signs include blood pressure 146/94 mm Hg, pulse 80/min, and respiratory rate 18/min. The nurse reviews the prescriptions from the provider. Which of the following prescriptions requires clarification? a. Methylergonovine 0.2 mg IM now. b. Insert an indwelling urinary catheter. c. Administer oxygen by nonrebreather mask at 5 L/min. d. Obtain laboratory study of prothrombin and partial thromboplastin time.

a. Methylergonovine 0.2 mg IM now.

A nurse is caring for a client whose Papanicolaou (Pap) test cytology results are abnormal. Which of the following procedures should the nurse anticipate for this client? a. Rectovaginal palpation by the provider b. Dilation and curettage c. Human chorionic gonadotropin (hCG) test d. Colposcopy

d. Colposcopy

A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data? a. The client is not experiencing a rubella infection at this time. b. The client is immune to the rubella virus. c. The client requires a rubella vaccination at this time. d. The client requires a rubella immunization following delivery.

d. The client requires a rubella immunization following delivery.

A nurse is teaching a newly licensed nurse about gynecological examination. Which of the following information should the nurse include in the teaching? a. A speculum is used to assess the perineum. b. The cervix is assessed by spreading the labia majora. c. The anal opening is assessed to visualize the Bartholin glands. d. The urethral orifice is assessed by separating the labia minora.

d. The urethral orifice is assessed by separating the labia minora.

A nurse is caring for a newborn who is small for gestational age (SGA). Which of the following findings is associated with this condition? a. Moist skin b. Protruded abdomen c. Gray umbilical cord d. Wide skull sutures

d. Wide skull sutures

A nurse is speaking with a 35-year-old client who has fibrocystic disease of the breasts. At which of the following times should the nurse inform the client that manifestations are most evident? a. Before menstruation begins b. After menstruation ends c. During cold weather d. During hot weather

a. Before menstruation begins

A nurse is providing teaching to the mother of a newborn born small for gestational age. Which of the following should the nurse include as a possible cause of this condition? a. Placental insufficiency b. Preterm delivery c. Fetal hyperinsulinemia d. Perinatal asphyxia

a. Placental insufficiency

A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider? a. Respiratory depression b. Facial flushing c. Nausea d. Drowsiness

a. Respiratory depression

A nurse is assessing a client for postpartum infection. Which of the following findings should indicate to the nurse that the client requires further evaluation for endometritis? a. Moderate amount of dark red lochia with a bloody odor b. A localized area of breast tenderness c. Pelvic pain d. Hematuria

b. A localized area of breast tenderness

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus? a. 3 cm above the umbilicus b. Slightly above the umbilicus c. Slightly below the umbilicus d. 3 cm below the umbilicus

b. Slightly above the umbilicus

A nurse is assessing a newborn for manifestations of a large patent ductus arteriosus. Which of the following findings should the nurse expect? a. Cyanosis with crying b. Systolic murmur c. Weak pulses d. Chronic hypoxemia

b. Systolic murmur

A nurse is caring for a client who is at 28 weeks of gestation and received terbutaline. Which of the following findings should the nurse expect? a. Fetal heart rate 100/min b. Weakened uterine contractions c. Enhanced production of fetal lung surfactant d. Maternal blood glucose 63 mg/dL

b. Weakened uterine contractions

A nurse is caring for a client who is in preterm labor with a current L/S ratio of 1:1. Which of the following actions should the nurse take? a. Infuse a bolus of IV fluid. b. Administer hydralazine 25 mg IV. c. Prepare the client for immediate delivery. d. Administer betamethasone 12 mg IM.

d. Administer betamethasone 12 mg IM.

A nurse is assessing a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breasts are hard and warm to palpation. Which of the following interpretations of these findings should the nurse make? a. The client is exhibiting early indications of mastitis. b. Additional interventions are not indicated at this time. c. Application of a heating pad to the breasts is indicated. d. The client should be advised to remove her nursing bra.

b. Additional interventions are not indicated at this time.

A nurse is caring for a client who is considering several methods of contraception. Which of the following methods of contraception should the nurse identify as being most reliable? a. A male condom b. An intrauterine device (IUD) c. An oral contraceptive d. A diaphragm with spermicide.

b. An intrauterine device (IUD)

A nurse is reviewing the health history of a client who has a new prescription for a combined oral contraceptive (COC). The nurse recognizes that which of the following client medications can interfere with the effectiveness of the COC? a. Antihypertensives b. Anticonvulsants c. Antioxidants d. Antiemetics

b. Anticonvulsants

A nurse is planning care for a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care? a. Position the newborn to promote extension of muscles. b. Use fingertips when calming the newborn. c. Cluster the newborn's care activities. d. Keep the newborn in a well-lit nursery.

c. Cluster the newborn's care activities.

A nurse is planning care for a client who is at 10 weeks of gestation and reports abdominal pain and moderate vaginal bleeding. The tentative diagnosis is inevitable abortion. Which of the following nursing interventions should be included in the plan of care? a. Administer oxygen via nasal cannula. b. Offer option to view products of conception. c. Instruct the client to increase potassium-rich foods in the diet. d. Maintain the client on bed rest.

b. Offer option to view products of conception.

A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following a vaginal birth. Which of the following actions should the nurse take? a. Apply an ice pack to the affected area. b. Offer a warm sitz bath. c. Provide a squeeze bottle of antiseptic solution. d. Place a hot pack to the perineum.

a. Apply an ice pack to the affected area.

A nurse is providing breast self-examination teaching to a client who is menopausal. Which of the following statements should the nurse identify as an indication that the teaching was effective? (Select all that apply.) a. "I don't have to lie down to check my breasts. I can stand in the shower." b. "If I feel a firm ridge in the lower curve of my breasts I should report this immediately." c. "It is important to press firmly when feeling my breasts to detect changes." d. "Since I no longer have periods, I can perform an examination at any time of the month." e. "I will make sure to feel for changes in my underarm area."

a. "I don't have to lie down to check my breasts. I can stand in the shower." d. "Since I no longer have periods, I can perform an examination at any time of the month." e. "I will make sure to feel for changes in my underarm area."

A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make? a. "It sounds like you are feeling sad that things didn't go as planned." b. "At least you know you have a healthy baby." c. "Maybe next time you can have a vaginal delivery." d. "You can resume sexual relations sooner than if you had delivered vaginally."

a. "It sounds like you are feeling sad that things didn't go as planned."

A nurse is teaching a client who has fibrocystic breast condition (FBC) about strategies to minimize discomfort. Which of the following instructions should the nurse include in the teaching? a. "Limit your dietary intake of salt prior to menses." b. "Reduce your fluid intake to 1 liter per day during menstruation." c. "Remove your bra at night while sleeping." d. "Take tub baths to avoid hot water running over your breast tissue."

a. "Limit your dietary intake of salt prior to menses."

A nurse is caring for a client who is menopausal and asks the nurse about the use of herbal therapies to reduce her discomfort. Which of the following statements should the nurse make? a. "Many herbal products have not undergone long-term testing for safety and efficacy." b. "Herbal therapies have no benefits and will not help your discomfort." c. "You should begin immediately as they will help you." d. "There are no ill effects associated with the use of herbal therapies."

a. "Many herbal products have not undergone long-term testing for safety and efficacy."

A nurse in a community clinic is counseling a client who received a positive test result for chlamydia. Which of the following statements should the nurse provide? a. "This infection is treated with one dose of azithromycin." b. "If your sexual partner has no symptoms, no medication is needed." c. "You have to avoid sexual relations for 3 days." d. "You need to return in 6 months for retesting."

a. "This infection is treated with one dose of azithromycin."

A nurse is teaching a client who has a new diagnosis of genital herpes. Which of the following statements by the client indicates the need for further teaching? a. "Transmission of the disease will not occur when my lesions are gone." b. "Abstaining from sexual activity reduces the risk of transmission of the disease." c. "The use of condoms will reduce the risk of transmission." d. "Antiviral medications will not cure the infection."

a. "Transmission of the disease will not occur when my lesions are gone."

A nurse in a family planning clinic is caring for a 17-year-old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make? a. "What part of the exam makes you most nervous?" b. "Don't worry, I will be with you during the exam." c. "All you need to do is relax." d. "A pelvic exam is required if you want birth control pills."

a. "What part of the exam makes you most nervous?"

A nurse is caring for a client who is in preterm labor at 32 weeks of gestation. The client asks the nurse, "Will my baby be okay?" Which of the following responses should the nurse offer? a. "You must be feeling scared and powerless." b. "Everyone worries about her baby when she's in labor." c. "Your pregnancy is advanced so your baby should be fine." d. "We have a neonatal unit here that's equipped to handle emergencies."

a. "You must be feeling scared and powerless."

A nurse is providing discharge teaching to a client following an abdominal hysterectomy. Which of the following information should the nurse include in the teaching? a. "You should refrain from sexual intercourse for at least 4 weeks." b. "You should expect to have burning with urination for the first week." c. "You should soak in a warm tub bath to ease incisional pain." d. "You should limit lifting to objects of 20 pounds or less."

a. "You should refrain from sexual intercourse for at least 4 weeks."

A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.) a. Administer magnesium sulfate IV. b. Provide a dark, quiet environment. c. Assess respiratory status every 4 hr. d. Evaluate neurologic status every 8 hr. e. Ensure that calcium gluconate is readily available.

a. Administer magnesium sulfate IV. b. Provide a dark, quiet environment. e. Ensure that calcium gluconate is readily available.

A nurse is reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? (Select all that apply.) a. Blot the perineal area dry after cleansing. b. Clean the perineal area from front to back. c. Perform hand hygiene before and after voiding. d. Apply ice packs to the perineal area several times daily. e. Wash the perineal area using a squeeze bottle of warm water after each voiding.

a. Blot the perineal area dry after cleansing. b. Clean the perineal area from front to back. c. Perform hand hygiene before and after voiding. e. Wash the perineal area using a squeeze bottle of warm water after each voiding.

A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor? a. Cervical dilation b. Report of pain above the umbilicus c. Brownish vaginal discharge d. Amniotic fluid in the vaginal vault

a. Cervical dilation

A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect? (Select all that apply.) a. Cracked, peeling skin b. Positive Moro reflex c. Short, soft fingernails d. Abundant lanugo e. Vernix in the folds and creases

a. Cracked, peeling skin b. Positive Moro reflex

A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take? a. Discontinue the medication infusion. b. Prepare for an emergency cesarean birth. c. Assess maternal blood glucose. d. Place the client in Trendelenburg position.

a. Discontinue the medication infusion.

A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first? a. Evaluate the firmness of the uterus. b. Initiate oxygen therapy by nonrebreather mask. c. Administer oxytocin infusion. d. Obtain a type and crossmatch.

a. Evaluate the firmness of the uterus.

A nurse is instructing a female client about how to check basal temperature in order to determine if the client is ovulating. The nurse should instruct the client to check her temperature at which of the following times? a. Every morning before arising b. On days 13 to 17 of her menstrual cycle c. 1 hour following intercourse d. Before going to bed every night

a. Every morning before arising

A nurse is caring for a client who is postpartum and received methylergonovine. Which of the following findings indicates that the medication was effective? a. Fundus firm to palpation b. Increase in blood pressure c. Increase in lochia d. Report of absent breast pain

a. Fundus firm to palpation

A nurse in a college health clinic is speaking to a group of adolescents about toxic shock syndrome (TSS). Which of the following should the nurse include in the teaching as increasing the risk for contracting TSS? a. High-absorbency tampons b. Mosquito bites c. Travel to foreign countries d. Multiple sexual partners

a. High-absorbency tampons

A nurse in a clinic is assessing a client who is at 8 weeks of gestation and has hyperemesis gravidarum. Which of the following findings should the nurse expect? (Select all that apply.) a. History of migraines b. Nulliparous c. Twin gestations d. History of gestational hypertension e. Oligohydramnios

a. History of migraines b. Nulliparous c. Twin gestations

A nurse is providing teaching to a client who has a new prescription for tamoxifen to treat breast cancer. The nurse should include that which of the following is an adverse effect of this medication? a. Hot flashes b. Insomnia c. Increased appetite d. Constipation

a. Hot flashes

A nurse is preparing to administer an injection of Rho (D) immunoglobulin. The nurse should understand that the purpose of this injection is to prevent which of the following newborn complications? a. Hydrops fetalis b. Hypobilirubinemia c. Biliary atresia d. Transient clotting difficulties

a. Hydrops fetalis

A nurse is caring for a term macrosomic newborn whose mother has poorly controlled type 2 diabetes. The newborn has respiratory distress syndrome. The nurse should be aware that the most likely cause of the respiratory distress is which of the following? a. Hyperinsulinemia b. Increased deposits of fat in the chest and shoulder area c. Brachial plexus injury d. Increased blood viscosity

a. Hyperinsulinemia

A nurse is caring for a newborn who has macrosomia and whose mother has diabetes mellitus. The nurse should recognize which of the following newborn complications as the priority focus of care? a. Hypoglycemia b. Hypomagnesemia c. Hyperbilirubinemia d. Hypocalcemia

a. Hypoglycemia

A nurse is teaching a client who is postpartum and has a new prescription for an injection of Rho (D) immunoglobulin. Which of the following should be included in the teaching? a. It prevents the formation of Rh antibodies in mothers who are Rh negative. b. It destroys Rh antibodies in mothers who are Rh negative. c. It destroys Rh antibodies in newborns who are Rh positive. d. It prevents the formation of Rh antibodies in newborns who are Rh positive.

a. It prevents the formation of Rh antibodies in mothers who are Rh negative.

A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client's ultrasound examination indicates that the fetus is small for gestational age (SGA). Which of the following interventions should be included in the newborn's plan of care? a. Observe for meconium in respiratory secretions. b. Monitor for hyperglycemia. c. Identify manifestations of anemia. d. Monitor for hyperthermia.

a. Observe for meconium in respiratory secretions.

A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take? a. Obtain blood glucose by heel stick. b. Initiate phototherapy. c. Monitor the newborn's blood pressure. d. Place the newborn in a radiant warmer.

a. Obtain blood glucose by heel stick.

A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time? a. Palpate the client's uterine fundus. b. Assist the client on a bedpan to urinate. c. Prepare to administer oxytocic medication. d. Increase the client's fluid intake.

a. Palpate the client's uterine fundus.

A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubinemia due to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons? a. The client's blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns. b. The client's blood contains the Rh factor and the newborn's does not, and antibodies that destroy red blood cells are formed in the fetus. c. The client has a history of receiving a transfusion with Rh-negative blood. d. The client's anti-A and anti-B antibodies cross the placenta and cause the destruction of the fetal red blood cells.

a. The client's blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns.

A nurse in the ambulatory surgery center is providing discharge teaching to a client who had a dilation and curettage (D&C) following a spontaneous miscarriage. Which of the following should be included in the teaching? a. Vaginal intercourse can be resumed after 2 weeks. b. Products of conception will be present in vaginal bleeding. c. Increased intake of zinc-rich foods is recommended. d. Aspirin may be taken for cramps.

a. Vaginal intercourse can be resumed after 2 weeks.

A nurse is teaching a newly licensed nurse about the purpose of a CA 125 test. Which of the following statements should the nurse include in the teaching? a. "A CA 125 test is used to confirm a diagnosis of ovarian cancer." b. "A CA 125 test is used to monitor a client's progress during treatment of ovarian cancer." c. "A CA 125 test is used to identify a Bartholin cyst." d. "A CA 125 test is used to measure testosterone level."

b. "A CA 125 test is used to monitor a client's progress during treatment of ovarian cancer."

A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn's mother asks about the swollen area on her son's head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse? a. "Mongolian spots can be found on the skin of many newborns." b. "A caput succedaneum occurs due to compression of blood vessels." c. "This is a cephalhematoma, which can occur spontaneously." d. "This is erythema toxicum, which is a transient condition."

b. "A caput succedaneum occurs due to compression of blood vessels."

A nurse in a prenatal clinic is teaching a client who is in her second trimester and has a new diagnosis of gestational diabetes. Which of the following statements by the client indicates a need for further teaching? a. "I should limit my carbohydrates to 50% of caloric intake." b. "I will reduce my exercise schedule to 3 days a week." c. "I will take my glyburide daily with breakfast." d. "I know I am at increased risk to develop type 2 diabetes."

b. "I will reduce my exercise schedule to 3 days a week."

A nurse in a prenatal clinic overhears a newly licensed nurse discussing conception with a client. Which of the following statements by the newly licensed nurse requires intervention by the nurse? a. "Fertilization takes place in the outer third of the fallopian tube." b. "Implantation occurs between 2 and 3 weeks after conception." c. "Sperm remain viable in the woman's reproductive tract for 2 to 3 days." d. "Bleeding or spotting can accompany implantation."

b. "Implantation occurs between 2 and 3 weeks after conception."

A nurse is providing teaching about Kegel exercises to a group of clients who are in the third trimester of pregnancy. Which of the following statements by a client indicates understanding of the teaching? a. These exercises help prevent constipation." b. "These exercises help pelvic muscles to stretch during birth." c. "They can help reduce back aches." d. "They can prevent further stretch marks."

b. "These exercises help pelvic muscles to stretch during birth."

A client at 36 weeks gestation has just delivered a stillborn baby. Which of the following statement should the nurse make? a. "I understand your grief. I lost a baby also." b. "You may hold your baby as long as you want." c. "I have called for the chaplain to come and stay with you." d. "This is for the best. Your baby was very ill."

b. "You may hold your baby as long as you want."

A nurse is caring for a client who asks to be screened for cervical cancer because a relative has been diagnosed with it. Which of the following tests should the nurse expect the provider to use? a. A serum prolactin level b. A Papanicolaou test c. A vaginal ultrasound d. An endometrial biopsy

b. A Papanicolaou test

A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients? a. A client who is experiencing fetal death at 32 weeks of gestation b. A client who is experiencing preterm labor at 26 weeks of gestation c. A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation d. A client who has a post-term pregnancy at 42 weeks of gestation

b. A client who is experiencing preterm labor at 26 weeks of gestation

A nurse is providing teaching to a client who has had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine cancer. Which of the following instructions should the nurse include in the teaching? a. A Papanicolaou (Pap) test should be performed every 6 months. b. Artificial lubrication can be used to treat vaginal itching and dryness. c. Increased vaginal drainage typically occurs 5 days following surgery. d. Resume sexual intercourse in 2 to 3 weeks.

b. Artificial lubrication can be used to treat vaginal itching and dryness.

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse? a. Assist the family to identify prior use of positive coping skills in family crises. b. Ask the client if she has considered harming her newborn. c. Anticipate a prescription by the provider for an antidepressant. d. Reinforce postpartum and newborn care discharge teaching.

b. Ask the client if she has considered harming her newborn.

A nurse in the emergency department is caring for a client who comes to the emergency department reporting severe abdominal pain in the left lower quadrant. The provider suspects a ruptured ectopic pregnancy. Which of the following signs indicates to the nurse that the client has blood in the peritoneum? a. Chvostek's sign b. Cullen's sign c. Chadwick's sign d. Goodell's sign

b. Cullen's sign

A nurse is caring for a newborn who has hydrocephalus. Which of the following manifestations should the nurse expect to find? a. Over-riding suture lines b. Dilated scalp veins c. Hypertension d. A backward sloping appearance of the forehead.

b. Dilated scalp veins

A nurse in an emergency department is performing an assessment on a client who reports being sexually assaulted. Which of the following actions should the nurse take first? a. Ask the client for permission to take photographs. b. Document the client's verbatim statements. c. Provide community sexual assault support contacts. d. Determine any physical signs of injury.

b. Document the client's verbatim statements.

A nurse is assessing a client who is 8 hr postpartum and multiparous. Which of the following findings should alert the nurse to the client's need to urinate? a. Moderate lochia rubra b. Fundus three fingerbreadths above the umbilicus c. Moderate swelling of the labia d. Blood pressure 130/84 mm Hg

b. Fundus three fingerbreadths above the umbilicus

A nurse in a provider's office is planning care for a client who has a new diagnosis of polycystic ovarian syndrome. The nurse should plan to monitor which of the following laboratory values? a. BUN b. Glucose c. Liver function d. Thyroid-stimulating hormone

b. Glucose

A nurse is caring for a client who is experiencing menopausal symptoms and asks the nurse about menopausal hormone therapy (HT). The nurse should inform the client that HT is not recommended due to which of the following findings in the client's medical history? a. History of dermatitis b. History of breast cancer c. Multiple hospitalizations for COPD d. Concurrent treatment for GERD

b. History of breast cancer

A nurse in a provider's office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption? a. Cocaine use b. Hypertension c. Blunt force trauma d. Cigarette smoking

b. Hypertension

A nurse is admitting a client who has a diagnosis of preterm labor. The nurse anticipates a prescription by the provider for which of the following medications? (Select all that apply.) a. Prostaglandin E2 b. Indomethacin c. Magnesium sulfate d. Methylergonovine e. Oxytocin

b. Indomethacin c. Magnesium sulfate

A nurse is caring for a male client who has a new diagnosis of genital herpes (HSV 2). Which of the following findings should the nurse expect? a. Anuria b. Influenza-like symptoms c. White- or flesh-colored papillary growths in the genital area d. Green penile discharge

b. Influenza-like symptoms

A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client's vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 36.4° C (97.6° F). Which of the following is the priority nursing action? a. Insert an indwelling urinary catheter. b. Initiate IV access. c. Witness the signature for informed consent for surgery. d. Prepare the abdominal and perineal areas.

b. Initiate IV access.

A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and reports heavy, red vaginal bleeding. The bleeding started spontaneously in the morning and is not accompanied by contractions. The client is not in distress and she states that she can "feel the baby moving." An ultrasound is scheduled stat. The nurse should explain to the client that the purpose of the ultrasound is to determine which of the following? a. Fetal lung maturity b. Location of the placenta c. Viability of the fetus d. The biparietal diameter

b. Location of the placenta

A nurse in a clinic is caring for a client who is at 11 weeks of gestation and reports that she has had slight occasional vaginal bleeding over the past 2 weeks. Following an examination by the provider, the client is told that the fetus has died and that the placenta, fetus, and tissues remain in the uterus. How should the nurse document these findings? a. Incomplete miscarriage b. Missed miscarriage c. Inevitable miscarriage d. Complete miscarriage

b. Missed miscarriage

A nurse is caring for a preterm newborn who has a nasogastric tube and who recently began intermittent gavage feedings of formula. The nurse notes increased abdominal distention, lethargy, bloody stools, and increasing gastric residuals before feedings. The nurse should suspect which of the following? a. Overstimulation b. Necrotizing enterocolitis c. Need for placement of a gastrostomy tube d. Intraventricular hemorrhage

b. Necrotizing enterocolitis

A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion? a. Diminished deep-tendon reflexes b. Respiratory rate of 16/min c. Urine output of 50 mL in 4hr d. Heart rate of 56/min

b. Respiratory rate of 16/min

A nurse is teaching a group of newly licensed nurses on effective techniques for counseling clients about sexually transmitted infections (STIs). Which of the following statements should the nurse include in the teaching? a. Use closed-ended questions when obtaining the health history." b. "A client's reproductive health history is not needed for counseling purposes." c. "Ask about the client's exposure to any past or present STIs." d. "Refer the client to genetic counseling if he has had a STI."

c. "Ask about the client's exposure to any past or present STIs."

A nurse is leading a discussion about contraception with a group of 14-year-old clients. After the presentation, a client asks the nurse which method would be best for her to use. Which of the following responses should the nurse make? a. "You are so young. Are you ready for the responsibilities of a sexual relationship?" b. "Because of your age, I think that a barrier method would be the best choice." c. "Before I can help you, I need to know more about your sexual activity." d. "A provider can help you with that after a physical examination."

c. "Before I can help you, I need to know more about your sexual activity."

A nurse in a clinic is caring for a client requiring a hysterectomy who states that she has decided to delay having this surgery for several months. Which of the following statements should the nurse make? a. "This type of surgery is very easy and should not cause a major disruption in your activities." b. "Most women don't have any problems during their recovery." c. "Can you elaborate on your reasons for delaying the surgery?" d. "If this happened to one of my family members, I would tell them to go ahead and not wait."

c. "Can you elaborate on your reasons for delaying the surgery?"

A nurse is providing teaching about comfort measures for breast engorgement to a client who is postpartum and is breastfeeding. Which of the following statements by the client indicates a need for further teaching? a. "I will breastfeed every 2 hours." b. "I will apply ice packs to my breasts after feeding." c. "I should apply hot packs to my breasts during feeding." d. "I should crush cabbage leaves and place them on my breasts."

c. "I should apply hot packs to my breasts during feeding."

A nurse is teaching a client who has vulvodynia about self-care measures to alleviate symptoms. Which statement by the client indicates an understanding of the teaching? a. "I should increase oxalates in my diet." b. "I should take baths instead of showers." c. "I should avoid the use of any lubricants." d. "I should wear cotton undergarments."

c. "I should avoid the use of any lubricants."

A nurse is caring for a client who is 6 hr postpartum. The client is Rh-negative and her newborn is Rh-positive. The client asks why an indirect Coombs test was ordered by the provider. Which of the following is an appropriate response by the nurse? a. "It determines if kernicterus will occur in the newborn." b. "It detects Rh-negative antibodies in the newborn's blood." c. "It detects Rh-positive antibodies in the mother's blood." d. "It determines the presence of maternal antibodies in the newborn's blood."

c. "It detects Rh-positive antibodies in the mother's blood."

A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor. The client has a new prescription for betamethasone and asks the nurse about the purpose of this medication. The nurse should provide which of the following explanations? a. "It is used to stop preterm labor contractions." b. "It halts cervical dilation." c. "It promotes fetal lung maturity." d. "It increases the fetal heart rate."

c. "It promotes fetal lung maturity."

A nurse at a family practice clinic receives a call from a client who is prescribed oral contraceptives but forgot to take one dose. The client reports she is in the first week of a 28-day cycle pack. Which of the following instructions should the nurse provide? a. "Do not have vaginal intercourse until after your next period." b. "Stop taking the pills and switch to a different contraceptive method." c. "Take the missed dose now, then continue the medication as ordered." d. "Take a home pregnancy test."

c. "Take the missed dose now, then continue the medication as ordered."

A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide? a. "There is an increased risk of introducing infection." b. "This could initiate preterm labor." c. "This could result in profound bleeding." d. "There is an increased risk of rupture of the membranes."

c. "This could result in profound bleeding."

A nurse is caring for an adolescent client who has pelvic inflammatory disease as a consequence of a sexually transmitted infection, and will need intravenous antibiotic therapy. The client tells the nurse, "My parents think I am a virgin. I don't think I can tell them I have this kind of an infection." Which of the following responses should the nurse make? a. "Give your parents a chance; they'll understand." b. "If you want me to, I can tell your parents for you." c. "You seem scared to talk to your parents." d. "Your parents will have to be told why you are being admitted."

c. "You seem scared to talk to your parents."

An RN from the maternal-newborn unit is being floated to a medical-surgical unit. Which of the following clients should the charge nurse on the medical-surgical unit plan to assign to the RN? a. A client who has terminal end-stage renal disease b. A client who has acute pancreatitis c. A client who is one-day postoperative following a total abdominal hysterectomy d. A client who had a stroke and is to be admitted

c. A client who is one-day postoperative following a total abdominal hysterectomy

A nurse in a clinic is reviewing the medical records of a group of clients who are pregnant. The nurse should anticipate the provider will order a maternal serum alpha-fetoprotein (MSAFP) screening for which of the following clients? a. A client who has mitral valve prolapse b. A client who has been exposed to AIDS c. All of the clients d. A client who has a history of preterm labor

c. All of the clients

A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9° C (102° F). Besides notifying the provider, which of the following is an appropriate nursing action? a. Recheck the client's temperature in 4 hr. b. Administer glucocorticoids intramuscularly. c. Assess the odor of the amniotic fluid. d. Prepare the client for emergency cesarean section.

c. Assess the odor of the amniotic fluid.

A nurse is caring for a client who is postpartum and has a prescription for Rho (D) immunoglobulin. The nurse should verify which of the following prior to administration? a. Client is Rh positive and the newborn is Rh positive. b. Client is Rh negative and the newborn is Rh negative. c. Client is Rh negative and the newborn is Rh positive. d. Client is Rh positive and the newborn is Rh negative.

c. Client is Rh negative and the newborn is Rh positive.

A nurse is completing discharge teaching to a client in her 35th week of pregnancy who has mild preeclampsia. Which of the following information about nutrition should be included in the teaching? a. Consume 40 to 50 g of protein daily. b. Avoid salting of foods during cooking. c. Drink 48 to 64 ounces of water daily. d. Limit intake of whole grains, raw fruits, and vegetables.

c. Drink 48 to 64 ounces of water daily.

A nurse is caring for a client who is 7 days postpartum and calls the clinic to report pain and redness of her left calf. Besides seeing her provider, which of the following interventions should the nurse suggest? a. Flex her knee while resting. b. Massage the area. c. Elevate her leg. d. Apply cold compresses.

c. Elevate her leg.

A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder? a. Increased urine output b. Vaginal discharge c. Elevated blood pressure d. Joint pain

c. Elevated blood pressure

A nurse is caring for a client who is at 22 weeks of gestation and has been unable to control her gestational diabetes mellitus with diet and exercise. The nurse should anticipate a prescription from the provider for which of the following medications for the client? a. Acarbose b. Repaglinide c. Glyburide d. Glipizide

c. Glyburide

A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which of the following should the infant receive? a. Hepatitis B immune globulin at 1 week followed by hepatitis B vaccine monthly for 6 months b. Hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen c. Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth d. Hepatitis B vaccine at 24 hr followed by hepatitis B immune globulin every 12 hr for 3 days

c. Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth

A nurse is caring for a client who has endometriosis and will receive depot injections of leuprolide. The client asks about the effects of this medication. Which of the following information should the nurse give the client? a. Menstruation will become regular. b. Vaginal secretions will increase. c. Hot flashes are common. d. Hair loss is common.

c. Hot flashes are common.

A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain? a. Administer prescribed analgesic medication. b. Encourage the client to rest between contractions. c. Massage the client's back. d. Turn the client onto her left side.

c. Massage the client's back.

A nurse is caring for a client who is 4 hr postpartum following a vaginal birth. The client has saturated a perineal pad within 10 min. Which of the following actions should the nurse take first? a. Assess client's blood pressure. b. Assess the bladder for distention. c. Massage the client's fundus. d. Prepare to administer a prescribed oxytocic preparation.

c. Massage the client's fundus.

A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn's plan of care? a. Monitor I&O. b. Monitor axillary temperature. c. Monitor blood glucose levels. d. Monitor weight.

c. Monitor blood glucose levels.

A nurse in a clinic is caring for a female client who was exposed to gonorrhea. Which of the following actions should the nurse take? a. Instruct the client about preventing reinfection by using a diaphragm. b. Tell the client to expect some joint pain. c. Obtain information about the client's recent sexual experiences. d. Collect a urine specimen from the client.

c. Obtain information about the client's recent sexual experiences.

A nurse is preparing to administer methylergonovine IM to a client who experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions? a. Postpartum infection b. Hypertension c. Postpartum hemorrhage d. Thromboembolic events

c. Postpartum hemorrhage

A nurse is teaching a group of young women about the use of oral contraceptives. The nurse should teach that taking which of the following herbal preparations reduces the effectiveness of this birth control method? a. Ginseng b. Gingko biloba c. St. John's wort d. Saw palmetto

c. St. John's wort

A nurse is reinforcing teaching about contraceptive methods with a client. Which of the following should the nurse recognize as a contraindication for diaphragm use? a. The client is 42 years old. b. The client smokes cigarettes. c. The client has pelvic relaxation. d. The client has a 3-month-old infant.

c. The client has pelvic relaxation.

A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis? a. Severe nausea and vomiting b. Large amount of vaginal bleeding c. Unilateral, cramp-like abdominal pain d. Uterine enlargement greater than expected for gestational age

c. Unilateral, cramp-like abdominal pain

A nurse is assessing a client who is receiving magnesium sulfate to treat pre-eclampsia. Which of the following findings should the nurse report to the provider? a. Respirations 16/min b. Headache for 30 min c. Urinary output 40 mL in 2 hr d. Fetal heart rate 158/min

c. Urinary output 40 mL in 2 hr

A nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification? a. Assess deep tendon reflexes every hour. b. Obtain a daily weight. c. Continuous fetal monitoring d. Ambulate twice daily.

d. Ambulate twice daily.

A nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications? a. Placenta previa b. Prolapsed cord c. Incompetent cervix d. Abruptio placentae

d. Abruptio placentae

A nurse is providing teaching to a client about the manifestations of uterine prolapse. Which of the following statements by the client should indicate to the nurse a need for further teaching? a. "The symptoms can get worse with penile penetration during intercourse." b. "A sensation of pressure in the pelvis can occur." c. "Low back pain can occur frequently." d. "Feces can be present in the vagina."

d. "Feces can be present in the vagina."

A nurse is teaching a group of teenage clients about the use of condoms for the prevention of sexually transmitted infections (STIs). Which of the following statements should the nurse include in the teaching? a. "Use a natural membrane condom rather than a polyurethane condom." b. "You may use a condom more than once." c. "Use an oil-based lubricant when you use a condom." d. "Female condoms can help prevent transmission of sexually transmitted viruses."

d. "Female condoms can help prevent transmission of sexually transmitted viruses."

A nurse is caring for a client who is 16 -hr postpartum and states "My baby has been breathing funny, fast and slow, off and on." Which of the following responses should the nurse provide? a. "Most new mothers feel somewhat anxious about things like this." b. "There's nothing for you to worry about. Newborns often breathe this way." c. "Why do you think there is something wrong with that?" d. "Let's sit here together and observe your baby while you feed him."

d. "Let's sit here together and observe your baby while you feed him."

A nurse is reviewing contraception options for four clients. The nurse should identify that which of the following clients has a contraindication for receiving oral contraceptives? a. A 26-year-old client who has migraine headaches at the start of each menstrual cycle b. A 28-year-old client who has a history of pelvic inflammatory disease c. A 32-year-old client who has benign breast disease d. A 38-year-old client who reports smoking one pack of cigarettes every day

d. A 38-year-old client who reports smoking one pack of cigarettes every day

A nurse on an obstetrics-gynecology unit is planning care for four clients after receiving change of shift report. Which of the following clients should the nurse assess first? a. A client who is a 1 day postpartum after a late term miscarriage b. A client who had a bilateral tubal ligation 12 hr previously c. A client who is 4 days postpartum and has mastitis d. A client admitted 1 hr ago for an ectopic pregnancy

d. A client admitted 1 hr ago for an ectopic pregnancy

A nurse is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the provider immediately? a. A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions b. A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors c. A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes d. A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache

d. A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache

A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first? a. A client who is at 38 weeks of gestation and reports a cough and fever b. A client who has missed a period and reports vaginal spotting c. A client who is at 14 weeks of gestation and reports nausea and vomiting d. A client who is at 28 weeks of gestation and reports of painless vaginal bleeding

d. A client who is at 28 weeks of gestation and reports of painless vaginal bleeding

A nurse is admitting a client who is at 33 weeks of gestation and has a diagnosis of placenta previa. Which of the following is the priority nursing action? a. Monitor vaginal bleeding. b. Administer glucocorticoids. c. Insert an IV catheter. d. Apply an external fetal monitor.

d. Apply an external fetal monitor.

A community health nurse is developing a pamphlet about breast self-examination (BSE) for a local health fair. Which of the following instructions should the nurse include? a. Expect some breast dimpling or discharge with age. b. For those who have a menstrual cycle, perform a BSE every month, 2 or 3 days before menstruation. c. Using the palm of the hand, feel for lumps using a circular motion. d. Breasts can be examined in the shower with soapy hands.

d. Breasts can be examined in the shower with soapy hands.

A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia? a. 1+ pitting sacral edema b. 3+ protein in the urine c. Blood pressure 148/98 mm Hg d. Deep tendon reflexes of +1

d. Deep tendon reflexes of +1

A nurse is assessing a newborn who was born at 42.5 weeks of gestation. Which of the following findings should the nurse expect? a. Copious vernix b. Scant scalp hair c. Increased subcutaneous fat d. Dry, cracked skin

d. Dry, cracked skin

A nurse in a clinic is interviewing a client who has a possible diagnosis of endometriosis. Which of the following findings in the client's history should the nurse recognize as consistent with a diagnosis of endometriosis? a. A history of pelvic inflammatory disease (PID). b. Abdominal bloating starting several days before menses. c. An atypical Papanicolaou smear at her last clinic visit. d. Dysmenorrhea that is unresponsive to NSAIDs.

d. Dysmenorrhea that is unresponsive to NSAIDs.

A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider? a. Headaches b. Nervousness c. Tremors d. Dyspnea

d. Dyspnea

A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client? a. Rapid decline in human chorionic gonadotropin (hCG) levels b. Profuse, clear vaginal discharge c. Irregular fetal heart rate d. Excessive uterine enlargement

d. Excessive uterine enlargement

A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify? a. Fetal attitude is in general flexion. b. Fetal lie is longitudinal. c. Maternal pelvis is gynecoid. d. Fetal position is persistent occiput posterior.

d. Fetal position is persistent occiput posterior.

A nurse is planning care for a client who is 2 hours postpartum following a cesarean birth. The client has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care? a. Apply warm, moist heat to the client's lower extremities. b. Massage the client's posterior lower legs. c. Place pillows under the client's knees when resting in bed. d. Have the client ambulate.

d. Have the client ambulate.

A nurse is caring for a client who is 12 hr postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication? a. Orthostatic hypotension b. Fundus palpable at the umbilicus c. Urine output of 3,000 mL in 12 hr d. Heart rate 110/min

d. Heart rate 110/min

A nurse is teaching for a client who is to begin taking tamoxifen to treat breast cancer. The nurse should instruct the client to expect which of the following findings as an adverse effect of the medication? a. Tinnitis b. Constipation c. Urinary retention d. Hot flashes

d. Hot flashes

A nurse is preparing to administer oxygen via hood therapy to a newborn who was born at 30 weeks of gestation. Which of the following is an appropriate nursing action when providing care to this infant? a. Remove the hood every hour for 10 min to facilitate bonding. b. Insert an orogastric tube for decompression of the stomach. c. Place the newborn in Trendelenburg position. d. Maintain oxygen saturations between 93% to 95%.

d. Maintain oxygen saturations between 93% to 95%.

A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client soaked a perineal pad in 10 min, the client's skin color is ashen, and she states she feels weak and light headed. After applying oxygen via nonrebreather face mask at 10 L/min which of the following actions should the nurse take next? a. Insert an indwelling urinary catheter. b. Administer oxytocin by continuous IV infusion. c. Tilt the client onto her right side with her legs elevated to at least 30°. d. Massage the client's fundus to promote contractions.

d. Massage the client's fundus to promote contractions.

A nurse in a clinic is teaching information about cervical polyps with a client who has a new diagnosis. Which of the following information should the nurse include in the teaching? a. Avoid using tampons during menstruation. b. Cervical polyps are a precursor to the development of cervical cancer. c. Cervical polyps affect women before the age of 40. d. Postcoital bleeding may occur.

d. Postcoital bleeding may occur.

A nurse is caring for a middle adult client who has just received the diagnosis of endometrial cancer. In taking a nursing history, which of the following manifestations is likely to be reported by this client? a. Unilateral swelling on the posterior of the vulva b. Extreme abdominal pain with intercourse c. Green, malodorous vaginal discharge d. Postmenopausal bleeding

d. Postmenopausal bleeding

A nurse is caring for a client who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 min. The nurse caring for her suspects placenta previa. Which of the following is an appropriate nursing action? a. Examination to determine cervical status b. A magnesium sulfate infusion c. Initiation of pushing d. Preparation for cesarean birth

d. Preparation for cesarean birth

A nurse is presenting educational materials for a group of middle-aged clients about menopausal hormone therapy following total hysterectomy. Which of the following information should the nurse include in the information? a. Take at different times of the day. b. Take an extra dose if missed a day. c. Prevents from having a cerebral hemorrhage. d. Prevents osteoporotic fractures.

d. Prevents osteoporotic fractures.

A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding? a. Tachycardia b. Absence of clonus c. Polyuria d. Report of headache

d. Report of headache

A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client? a. Temperature b. Fetal heart rate (FHR) c. Bowel sounds d. Respiratory rate

d. Respiratory rate

A nurse is caring for a client who is postoperative following a right-sided mastectomy and has a drain connected to a portable drainage evacuator. Which of the following actions should the nurse? a. Dangle the operative limb for 5 min every hour. b. Place the head of the client's bed at a 15° angle. c. Keep the wound drain evacuator fully expanded at all times. d. Take blood pressures on the client's non-affected arm.

d. Take blood pressures on the client's non-affected arm.